31 July 2007

An acceptable level of shag-ups

In the news reporting on reinstatement of a Gander radiologists suspended after questions were raised about his work, Central Health chief executive Karen McGrath is quoted as pointed to the absence of benchmarks for judging physician performance in conducting the evaluation.
Meanwhile, Central Health chief executive officer Karen McGrath said the authority would like provincial and federal governments to develop clear rules on how to review the competence of physicians.

"It would have been much easier for us if we had definitive information with respect to benchmarks," she said. "The reality was we had to go with the best information we had."
That's similar to her comments on the day McGrath announced the doctor would be reinstated and that, as vocm.com reported,"no significant adverse patient results have been discovered."

As cbc.ca/nl is reporting on Tuesday,
McGrath said that of a sample of about 500 tests generated by the Paton Hospital radiologist, fewer than 10 per cent were questionable. She said that is within an acceptable margin of error.
McGrath's comments are curious for several reasons.

Firstly, notice the numbers. Out of the 500 reports reviewed, less than 10% were found to have results that were "questionable."

That means that fewer than 50 of those reports weren't accurate.

But to say "questionable" - if that's the word McGrath used - is pretty vague, and it's needlessly vague.

A quick search of the Internet will reveal more than a few discussions in peer reviewed journals on error rates - often called missed observations - among radiologists.

Medically significant missed observations do occur; that is, radiologists sometimes miss things that are important to the treatment of a patient. They may do it for very good reason, like a cancerous mass obscured by body fat.

Other observations may be missed simply because they aren't medically significant. They may not be missed - in that the doctor didn't see them - they may just be not reported because in the expert opinion of the doctor reviewing the records, they aren't worth mentioning.

It's a judgement call. If it isn't medically important, then not reporting them isn't "questionable" whether McGrath used that word or a similar term.

McGrath apparently didn't make that sort of distinction. If she did, it is extremely important for someone in authority to correct the news report. If she didn't, McGrath may want to be a bit more precise in her language.

If there were no medically significant errors - that is, if no changes to treatment were required - then that simple fact should have been indicated clearly to reporters.

Secondly, each regional health authority and even each hospital can and should establish standards of acceptable medical performance. If nothing else, having those standards is a way of ensuring that people working in a hospital are actually doing the job they are supposed to be doing in keeping with best practices.

It's astonishing that McGrath would even raise the question about a supposed lack of standards. Her comment is akin to members of the House of Assembly - who set the rules for how they manage their own cash - claiming that there were no rules, when in fact there were rules, and the person complaining is the one responsible for setting the rules.

To say there were no benchmarks to use suggests that people have been winging it in Gander.

Now if, by some bizarre chance, neither McGrath nor her medical staff had the vaguest clue about how to judge a radiologist's job performance - that's the implication of her comment - then she and her officials can consult other health authorities, the provincial association representing radiologists, the national radiology association or the provincial college governing doctors and asked any or all of them for help.

If the issue that turned up her was a matter of insignificant missed observations, then McGrath and her senior administrative staff are completely within their authority to establish minimum reporting standards.

Thirdly, one can easily consider that McGrath's comment was a call for setting an acceptable number of mistakes a radiologist can commit. That isn't what she intended and the interpretation is somewhat facetious.

But if you think about it for a second, saying there are no standards to judge performance and that less than 10% is acceptable in this case, McGrath is signalling to both patients and their doctors that there is or should be an entirely arbitrary benchmark for shag-ups.

The reality is that both doctors and patients expect the standard is zero errors. Doctors work diligently to avoid any mistakes, let alone ones that will cause problems for the patient. They recognize, however, that mistakes do occur for many reasons.

The doctors, the hospital administration and ultimately the medical regulatory authorities have developed systems to minimise the chance of medically significant error, to figure out what occurred when mistakes happen and then to take appropriate action to make sure mistakes don't happen again.

Each case has to be handled on its merits and, where circumstances warrant, the provincial college of physicians and surgeons can and should be involved. It's part of a system and it's a system that generally works. That isn't the message one gets from McGrath's remarks.

The way McGrath's remarks have been reported, a patient in the province can think that the health care system is flying a bit by the seat of everyone's britches. It's not exactly a way to restore public confidence in the system generally and in a town like Gander - where likely everyone knows the name of the suspended radiologist - it's hardly a way to restore confidence in his or her abilities.

To be fair, Central Health hasn't had to carry the burden of the minister's office on this case, so overall their handling of it has been better than the experience in Eastern Health on a similar matter.

But still.

Health care is the one area where people generally don't think there is an acceptable level of shag-ups.

No one should be suggesting otherwise. More information, let alone more accurate information, would go a long way to dispelling any concerns, avoid misconceptions and restore public confidence.

And if all this is based on inaccurate reporting, then maybe Central Health should consider posting the facts - maybe in a news release - on its website.

This could have been the first one.